Report on Medicare Compliance

  1. Hospital Settles FCA Case Filed by CO Over Modifiers; Make Sure People ‘Feel Heard’

    Report on Medicare Compliance Volume 30, Number 32. September 13, 2021  | Author: Nina Youngstrom  | September 13, 2021 

    John Peter Smith (JPS) Hospital in Fort Worth, Texas, agreed to pay $3.3 million to settle false claims allegations in a case with a hot risk area, a compliance officer-turned-whistleblower and a self-disclosure. Erma Lee, the former director of compliance, alleged the hospital improperly billed for three modifiers and didn’t return the overpayments even after she alerted executives, according to her 2018 False Claims Act (FCA) complaint.[1] During the subsequent Department of Justice investigation, the hospital voluntarily repaid its Medicare administrative contractor $438,673, according to the settlement, which was announced by the U.S. Attorney’s Office for the Northern District of...

  2. CMS Voids Mid-Build Audit Findings; New Audit Will Use Broader Construction Interpretation

    Report on Medicare Compliance Volume 30, Number 32. September 13, 2021  | Author: Nina Youngstrom  | September 13, 2021 

    CMS on Sept. 10 withdrew its determination that 202 provider-based departments (PBDs) flunked audits of the mid-build exception, which allows certain PBDs established after Nov. 2, 2015, to bill the outpatient prospective payment system (OPPS)...

  3. AG Yanks Brand Memo; DOJ ‘May Rely on Relevant Guidance Documents’

    Report on Medicare Compliance Volume 30, Number 32. September 13, 2021  | Author: Nina Youngstrom  | September 13, 2021 

    In a new memo, Attorney General Merrick Garland gave prosecutors at the Department of Justice (DOJ) the green light to incorporate subregulatory guidance, such as Medicare manuals, into their enforcement actions, reversing a position taken by the Trump administration.[1] But Garland reiterated that guidance doesn’t have the force of law, and “enforcement actions must be based on the failure to comply with a binding obligation, such as one imposed by the Constitution, a statute, a legislative rule, or a contract.”...

  4. Chief Compliance Officer 2021 Survey: Compliance Imperatives

    Report on Medicare Compliance Volume 30, Number 32. September 13, 2021  | Author: Nina Youngstrom  | September 13, 2021 

    Here are some of the findings from the KPMG 2021 Chief Compliance Officer Survey,[1] which represents responses from 249 chief compliance officers from large global organizations across various industries, including health care, life sciences, banking, capital markets and insurance, industrial manufacturing, consumer markets and retail, technology, media and telecommunications, and energy. Request the survey at https://bit.ly/3tsoNA9...

  5. CMS Transmittals and Federal Register Regulations, Aug. 27-Sept. 9, 2021

    Report on Medicare Compliance Volume 30, Number 32. September 13, 2021  | September 13, 2021 

  6. News Briefs: September 13, 2021

    Report on Medicare Compliance Volume 30, Number 32. September 13, 2021  | Author: Nina Youngstrom  | September 13, 2021 

    ◆ Saint Francis Medical Center in Missouri agreed to pay $1.625 million in a civil settlement of allegations it violated the Controlled Substances Act, the U.S. Attorney’s Office for the Eastern District of Missouri said Sept. 1.[1]  According to the U.S. attorney’s office, Saint Francis employed Farmington physician Brett Dickinson, who allegedly “wrote prescriptions for controlled substances without legitimate medical purposes and outside the usual course of professional practice.” The hospital, through Dickinson’s actions, “issued invalid prescriptions for opioids such as morphine, hydromorphone, and oxycodone,” the U.S. attorney’s office alleged. “Dickinson prescribed these opioids to patients simultaneously with muscle relaxers and...

  7. Another Delay for Appropriate Use Penalties Is Proposed; Hospitals Still Find Glitches

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    Partly because of the COVID-19 pandemic, CMS is again planning to delay pulling the trigger on the penalty phase of the appropriate use criteria (AUC) requirement for advanced diagnostic imaging, which was scheduled to take effect in January 2022, according to the 2022 proposed Medicare Physician Fee Schedule (MPFS) rule.[1] If the delay is finalized, penalties for not getting an AUC consultation will kick in Jan. 1, 2023, or at the end of the year in which the public health emergency is over (whichever is later), and eventually outlier physicians will be put on prior authorization. The extra time could...

  8. Excerpt From Appropriate Use Criteria Tip Sheet

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    Here’s a small excerpt of a tip sheet developed by UNC Health in North Carolina to help its providers navigate Medicare’s appropriate use criteria (AUC) for advanced diagnostic imaging,[1] said Patrick Kennedy, executive director of hospital compliance. The AUC requirement includes the use of a clinical decision support mechanism. UNC is using CareSelect as its clinical decision support mechanism, and the tip sheet includes screenshots of the predicted indications based on “an artificial intelligence algorithm that uses information from the medical record to dynamically predict the most relevant indications.” Contact Kennedy at patrick.kennedy@unchealth.unc.edu...

  9. Not the Usual Risk: CCOs Worry About Caregiver Well-Being, Other COVID-19 Ripple Effects

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    The mental and physical well-being of caregivers probably didn’t show up on any pre-COVID-19 work plan, but times change, and some compliance officers think it’s a top risk for 2022...

  10. Proposed IPO List Reversal Eased by Point-of-Entry Case Managers

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    Because its point-of-entry case managers review all planned surgeries in advance, ProHealth Care Inc. in Waukesha, Wisconsin, is taking CMS’s plan to reverse the elimination of the inpatient-only list (IPO), which was announced in the 2022 proposed outpatient prospective payment system regulation,[1] in stride. They act as a buffer between physicians and the compliance requirements, asking for inpatient orders for IPO procedures whether or not patients are expected to stay two midnights...

  11. Value-Based Exceptions Are Escape From ‘Traditional’ FMV Standards

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    When a hospital sets up a clinic at a homeless shelter, it offers a generous salary to entice physicians to work there. Because the clinic is a value-based enterprise (VBE) that complies with one of the new value-based exceptions in the revised Stark Law regulation,[1] the hospital is able to pay the physicians a salary that doesn’t meet traditional fair market value standards (e.g., productivity compensation). The goal of the VBE is to treat minor illnesses that tend to land homeless and uninsured people in the emergency room, sparing it from sore throats and other routine complaints that are better...

  12. A Quick Guide to the Requirements of the Stark Value-Based Exceptions

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    Bob Wade, an attorney with Barnes & Thornburg, and Randy Biernat, a partner at BKD, described the three exceptions for value-based care in the revised Stark Law regulation[1] at an Aug. 24 virtual conference sponsored by the American Association of Provider Compensation Professionals.[2] Contact Wade at bob.wade@btlaw.com and Biernat at rbiernat@bkd.com...

  13. News Briefs: August 30, 2021

    Report on Medicare Compliance Volume 30, Number 31. August 30, 2021  | Author: Nina Youngstrom  | August 30, 2021 

    ◆ Carenow Services LLC, a psychotherapy services provider based in Roswell, Georgia, and its CEO, Leena Karun, agreed to pay $2 million to settle false claims allegations that they billed Medicare and Medicaid for psychotherapy at nursing homes and skilled nursing facilities that was medically unnecessary, improperly documented or upcoded from 2012 to 2018, the U.S. Attorney’s Office for the Northern District of Georgia said Aug. 25.[1] The case was initiated by a former employee turned whistleblower. “Consistent with the Justice Manual, the settlement includes credit to Carenow for immediately cooperating with the government in this investigation and for promptly...

  14. Health System Pays $4.3M in Settlement Over Observation for Patients Discharged From ER

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | Author: Nina Youngstrom  | August 23, 2021 

    In a case that captures many of the ways that billing for observation can go wrong, Sentara Healthcare has agreed to pay $4.33 million in a civil monetary penalty settlement with the HHS Office of Inspector General (OIG). The settlement stemmed from a self-disclosure by Sentara, which owns hospitals, outpatient centers and other entities in Virginia and North Carolina...

  15. CMS Plan to Bundle Critical Care In Global Surgery May Disrupt Billing, Compliance

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | Author: Nina Youngstrom  | August 23, 2021 

    Clouds are gathering over a proposal in the 2022 Medicare Physician Fee Schedule (MPFS) rule[1] to prohibit billing for critical care services provided during the global surgery period, according to an attorney. It’s unclear how physicians would comply with the billing restriction when they provide critical care without knowing the patient had recent surgery...

  16. Training Content Should Be Like an Executive Summary, Expert Says

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | Author: Nina Youngstrom  | August 23, 2021 

    Compliance professionals are accustomed to spending some of their time walking the beat, hearing concerns from people and sharing information. When they went home to work because of the COVID-19 public health emergency, some compliance professionals reported losing their ability to “plug into the culture,” as one expert put it...

  17. DOJ: Tailored Training Is a ‘Hallmark’ of an Effective Compliance Program

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | August 23, 2021 

    The Department of Justice’s June 2020 update to its Evaluation of Corporate Compliance Programs emphasizes the importance of training.[1] Below is the main section, but training is mentioned in other parts of the document. “There is in compliance often a hesitation to move away from in-depth, substantive training,” said Kirsten Liston, a principal at Rethink Compliance, who has six principles for great training.[2] “DOJ has given you a get-out-of-jail-free card. They are saying, ‘We will accept shorter training if it gets the job done, and it’s your responsibility to prove it.’” Some exhaustive training is mandatory, however, such as Medicare...

  18. DOJ Intervenes in FCA Complaints Against Kaiser Plan, Medical Groups

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | Author: Nina Youngstrom  | August 23, 2021 

    The Department of Justice (DOJ) has intervened in six whistleblower lawsuits alleging that Kaiser Foundation Health Plan and other members of the Kaiser “consortium,” including medical groups, submitted inaccurate diagnosis codes to increase Medicare Advantage (MA) reimbursement. The false claims complaints allege Kaiser pressured physicians to produce addenda to medical records after the fact with risk-adjusting diagnoses that patients didn’t have and/or weren’t addressed, DOJ said July 30.[1] The higher the risk, the more money CMS pays MA plans for their enrollees...

  19. CMS Transmittals and Federal Register Regulations, Aug. 13-19, 2021

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | August 23, 2021 

  20. News Briefs: August 23, 2021

    Report on Medicare Compliance Volume 30, Number 30. August 23, 2021  | Author: Nina Youngstrom  | August 23, 2021 

    ◆ Blessing Hospital in Quincy, Illinois, has agreed to pay about $2.82 million to settle false claims allegations in connection with medically unnecessary cardiac catheterization procedures performed by a physician who doesn’t practice in central Illinois anymore, the U.S. Attorney’s Office for the Central District of Illinois said Aug. 17.[1] The settlement, which stems from the hospital’s voluntary self-disclosure, resolves allegations that the hospital was paid the facility portion of cardiac catheterizations performed from Aug. 1, 2012, to Aug. 30, 2018, when the interventional cardiologist implanted medically unnecessary coronary arterial stents. In a statement, the hospital said the physician, who...

  21. Hospital Settles FCA Case Over Social Admissions; Whistleblower Also Alleged Retaliation

    Report on Medicare Compliance Volume 30, Number 29. August 16, 2021  | Author: Nina Youngstrom  | August 16, 2021 

    In a case about social admissions, San Mateo Medical Center (SMMC) and San Mateo County in California have agreed to pay $11.4 million to settle false claims allegations in connection with billing Medicare for medically unnecessary inpatient admissions, partly because the patients had no other place to go, the Department of Justice said Aug. 6.[1] The case was set in motion by a whistleblower, former hospital employee Felix Levy, who alleged in his False Claims Act (FCA) complaint that SMMC retaliated against him for raising billing concerns—including an allegation that someone from the hospital told the police that Levy was...

  22. Enforcers Turn Their Attention to Possible Failures With Charity Care, Clinical Standards

    Report on Medicare Compliance Volume 30, Number 29. August 16, 2021  | Author: Nina Youngstrom  | August 16, 2021 

    The potential failure of a nonprofit hospital to comply with its charity care obligations is gaining momentum as a compliance risk, as some state attorneys general focus on this area and it’s featured in media accounts, according to a longtime state and federal watchdog. He suggests compliance professionals take an interest in Schedule H of IRS Form 990, where tax-exempt hospitals report patient financial assistance and other community benefits...

  23. OIG: Fake Vaccine Cards, Lab Tests Are Among Evolving COVID-19 Scams

    Report on Medicare Compliance Volume 30, Number 29. August 16, 2021  | Author: Nina Youngstrom  | August 16, 2021 

    It’s “mind boggling” to Elton Malone, assistant HHS inspector general for investigations, that some people would rather pay $200 for a fraudulent COVID-19 vaccine card than get a bona fide vaccine that protects them from the deadly virus for free. Phony vaccine cards are one type of fraud OIG is seeing in connection with the COVID-19 pandemic. It’s “prevalent,” Malone said, but it’s not the only kind of fraud related to vaccines. They’re also being diverted by warehouse workers in charge of disposing of expired vaccines and by truck drivers who are supposed to drive them to the offices of...

  24. CMS Transmittals and Federal Register Regulations, July 30-Aug. 12, 2021

    Report on Medicare Compliance Volume 30, Number 29. August 16, 2021  | August 16, 2021 

  25. News Briefs: August 16, 2021

    Report on Medicare Compliance Volume 30, Number 29. August 16, 2021  | Author: Nina Youngstrom  | August 16, 2021 

    ◆ Targeted Probe and Educate (TPE) is back, CMS said in an Aug. 12 MLN Connects.[1] CMS is restarting TPE “to help educate providers and reduce future denials and appeals. If your Medicare Administrative Contractor audits you, take advantage of the TPE education, and get up to 3 rounds of educational claim review to help you bill accurately.” CMS has a TPE page on its website.[2]...